Revised Dec 08
SUPERVISOR’S OWCP CHECKLIST
Name:__________________________DOI:_____________Claim#:___________
1. Injury Reported -
Employee reports incident by completing OSHA form at websitehttps://www.ecomp.dol.gov/#Employee may then access CA 1, Traumatic Injury or CA 2,Occupational Disease claim formSupervisor receives email notice of OSHA form and or CA 1 or 2 form to complete
2. Notify Safety -
Upon receipt of OSHA 301 email notification, review and forwardform to Safety Designee
3. Medical Documentation –Upload into WEEDS (Mustbe signed byphysician)
CA-16, Authorization for examination (only issue within 48hrs of injury)CA-20, Attending Physician’s Report (each time medial treatment received)CA-17, Duty Status Report (must submit after each treatment)Injured employee must notify physician that Agency offers light duty
4. Continuation of Pay (COP) –Must be supported by medical documentation
45 calendar daysentitlement following date of traumatic injuryTime card code for COP: LU for date of injury and LT 45 days after injuryFour digit code for time card is month and day of injuryIf claim is denied, change COP to LS, LA or LWOPNotify ICPA when COP is used(supporting medical documentation required)
5. Medical Authorization –Must be supported by medical justification
Physician requests authorization: phone(844) 493-1966,fax (800) 215-4901, http://owcp.dol.acs-inc.comMedical Provider must haveACS Provider Numberto receive authorizationPhysician must state ICD-9, diagnosis code and CPT, procedure code
6. Compensation after 45 days –IF NEEDED-Must be supported by medical documentation
Must be in LWOP (Leave Without Pay) statusCA-7, Claim for Compensation (submit every two weeks)SF-1199A, Direct Deposit Sign-upAfter 80hrs of LWOP, submit SF-52 to HRO requesting LWOP statusPay rate is three-fourths (3/4)withdependents and two-thirds (2/3)withoutdependents
7. Medical Bills –
Website: http://owcp.dol.acs-inc.com (Provider search is available on this site)Medical Provider must haveACS Provider Numberto receive paymentBills submitted manually must be submitted on HCFA-1500 or UB-92Mailing Address: ACS Customer Service:(844) 493-1966
8. Reimbursement –IF NEEDED
OWCP-915 -Medical andOWCP-957 -Travel – Submit with required documentation to ICPA
9. Agency Point of Contact – ICPA:
State HeadquartersAddressStreetCity/State/Zip
Phone:Fax:E-mail:
USDept ofLabor-OWCPPOBox 8300London, KY 40742-8300
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